Provider Demographics
NPI:1245394642
Name:SHUPP, MICHELLE (BSW,CSCAD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SHUPP
Suffix:
Gender:F
Credentials:BSW,CSCAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13114 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2741
Mailing Address - Country:US
Mailing Address - Phone:240-313-3329
Mailing Address - Fax:
Practice Address - Street 1:740 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:240-313-3329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC1885101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD705371101Medicaid